Authorization to Release/Not Release Medical Information

for patients 18 yrs old or older

Please correct the errors described below.

Patient's First and Last Name

Phone Number

To Release

I (name)

give permission to University Pediatric Associates, staff to discuss any medical conditions with my Parent(s)/Guardian(s).
This includes providing them with any copies of my medical records as requested by them.

This authorization will remain in effect until I choose to retract it.

Signature

Date

To Not Release

I (name)

decline giving permission to University Pediatric Associates staff to discuss any medical conditions with my Parent(s)/Guardian(s).
This includes providing them with any copies of my medical records as requested by them.

This authorization will remain in effect until I choose to retract it.